The Montana Mental Health Nursing Care Center in Lewistown, touted in early 2017 as being one of the best in the country for two years in a row, now has a below-average rating and the state has been forced to hire a consultant and pay fines, pumping in what is turning out to be hundreds of thousands of dollars, to correct problems.

The Medicaid-licensed facility is the only one of its kind in Montana, state officials said, as it is certified as a mental health and a long-term care operation, housing residents who cannot benefit from the intensive psychiatric treatment available at Montana State Hospital in Warm Springs.

A Feb. 22 inspection found the state-run facility failed to protect people from fellow residents who showed verbal, physical and sexually abusive behaviors in the Firefly Wing, which houses dementia patients. Three residents had suffered physical, mental and psychosocial harm from the aggressors.

It included comments from one of the medical providers who accused the current administration of creating a "toxic environment."

The Immediate Jeopardy finding came with a civil money penalty by the Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) of $12,759 per day for 20 days, Feb. 22 to March 13, for a total of $255,180. Due to the removal of the immediate jeopardy situation, the civil monetary penalty was lowered to $505 per day from March 14 to April 26, for a total of $22,220, state officials said.

After an April 26 revisit survey, the penalty was lowered to $105 per day and will continue until the facility is in substantial compliance with all participation requirements, state officials said.

State officials note that federal law was changed in 2016 mandating a fine be ordered any time Immediate Jeopardy is cited. They said civil monetary penalties are up 500 percent statewide since the implementation of the new policy.

State officials said they were mandated by federal officials to hire consultants, Colorado-based Vivage was selected, and the contract ranges for $60,000 to $80,000 a month for as long as a year. Those officials said they hope Vivage will complete its work in a total of four months, ending in June.

State officials said one reason for the lower grade was due to a substantial change in nursing home requirements from the federal government, and they have confidence in the facility’s administration.

“The gist of it is we are still providing the same quality care but with a different set of regulations and a different set of expectations,” said Zoe Barnard, administrator of the Addictive and Mental Disorders Division of the Montana Department of Public Health and Human Services, which oversees the nursing care center.

However, federal officials said states were given ample time to prepare for the new regulations and should not have been surprised.

The new requirements include new definitions for abuse, exploitation, misappropriation of resident property and neglect. It also includes new information on residential rights, same sex spouses, resident care and promoting “resident self-determination.

If the state does not comply, the federal government could pull the Medicare and Medicaid funding for the site, officials said.

In a Jan. 31, 2017, news release the state said the facility had achieved “the highest rating possible from the annual U.S. News and World Report Best Nursing Homes for 2016-2017. They said it had earned “the highest five-star mark” from CMS.

But Medicare.gov, which says it is the official U.S. site for Medicare, now gives Montana Mental Health Nursing Care Center an overall rating of two stars, or “below overage.”

The survey also found “immediate jeopardy” at the facility,” meaning, according to federal guidelines, that situations occurred in which the provider's noncompliance with requirements “has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”

The investigation, described as a “complaint survey,” found that on 13 occasions the administrator and other officials were not notified of incidents that included physical, mental, psychosocial and sexual abuse in the Firefly Wing.

According to federal officials, Vivage has placed a temporary manager at the site to oversee bringing into compliance. The state's administrator, Dianne Scotten, is still required per state rules to be at work during this time.

Steven Chickering, associate regional administrator for CMS, said it has proven to be the best way to bring about change.

“There are times we feel the oversight of a facility by the administrator is not effective or they have the capability to help the facility to do what it takes,” he said.

Centers for Medicare and Medicaid Services.(Photo: U.S.Department of Health and Human Services)

The hiring of consultants comes at a time at DPHHS is cutting $49 million in services due to lower than expected state budget revenues and a costly fire season.

“We didn’t have any choice,” Barnard said.

“The consultants CMS has referred to us are helping us to revise our policies and procedures so that we are in compliance with federal regulations,” she said.

Barnard said the consultants were required because of the resident-on-resident touching. She said the behavior is not unusual among dementia patients.

“Demented people become very sexualized,” she said. “It’s very common.”

Barnard said it sounds disturbing, especially when read in print.

“It’s a constant challenge from a supervision standpoint to make sure residents are not inappropriately touching each other,” she said.

The 171-page inspection report by CMS found that one of the center’s medical providers, identified as “NF2,” says the facility at one time had an excellent history but the current administration had created “a toxic environment.”

He was let go from his job May 9 as he was seeking permission from Central Montana Medical Center, the hospital that contracts with the mental health center to speak to this newspaper. He said according to the contract with the mental health center he could be dismissed without reason.

The hospital did not return a call seeking comment.

NF2, or as he is known beyond the report, Dr. J.D. Moore, said had worked for the center on and off for 18 years.

When asked in a telephone interview if he is NF2 and is read some of the comments in the survey, Moore says “That sounds like me.”

NF2 told the inspector he had filed an official concern with the facility’s leadership, which is the level above the administration.

“He felt the leadership of administration was incompetent and they make poor decisions,” the inspector wrote.

The Montana Mental Health Nursing Care Center did not submit a plan to correct problems outlined in the Feb. 22 survey before the inspectors left, which is sometimes done, and had offered a plan March 8 that was approved by CMS.

A June 23, 2017, survey also found an “immediate jeopardy” situation after looking into allegations from residents of staff abuse.

The report also details allegations by a resident who said staff “terrorized” and threatened him and suspended him during a transfer with a lift.

In another incident a resident reported being lifted out of the chair and being held by the lift for an hour and telling the staff member “it hurts so much.”

“I know,” the staff member allegedly replied.

Staff members in the February survey told inspectors the care center was “the last best place and that the residents had nowhere else to go.”

Another staff member said they had done the best they could under the circumstances and “the no one else would probably have taken the residents with aggression (issues), but they had to.”

State officials said in order for people to be admitted to the center, applicants must be refused from three private nursing homes.

Center is unique

Founded in 1952, the nursing care center is the only one of its kind in Montana as it is certified as both a mental health and a long-term care operation, officials said. It is a 117-bed Medicaid-licensed facility.

Some of the residents have been put into the custody of the DPHHS and placed there because putting them in a jail or prison would not be appropriate. According to the DPHHS, the average stay of patients is just a little more than two years.

More than 70 percent of its residents are over age 65 and all have a mental health diagnosis, officials said.

It is for long-term placement and treatment of people with mental disorders who require a level of care not available in the public sector. They have been turned away by other nursing homes or community placements, the state said in its Jan. 31, 2017, news release.

They have been determined to be a danger to themselves and others; require long-term care; and cannot benefit from the intensive psychiatric treatment available at the Montana State Hospital.

The news release said there were 135 full-time equivalent employees. Barnard said on May 15 that there were 80 residents.

Its mission statement says: “We are dedicated to delivering the best possible care with courtesy, efficiency and respect. We are committed to providing high-quality resident care in a safe environment, using the least restrictive methods that meet our residents’ physical and emotional needs.”

Five-star rating

In October 2016, U.S. News and World Report gave the nursing home the highest five-star mark for 2016-2017 based on factors such as food preparation, medication management and residents’ rights.

The state heralded that in its news release.

“It really takes lot of teamwork to earn a 5-star ranking,” Scotten said, in which she also credits staff. “This recognition shows that we are consistently performing at a high level.”

U.S. News and World Report said it used data provided by CMS to evaluate more than 15,000 homes over a year and 10 percent of nursing homes in Montana and 13 percent nationwide were given the U.S. News Best Nursing Home designation.

But Medicare.gov, which says it is the official U.S. site for Medicare, now gives Montana Mental Health Nursing Care Center an overall rating of two stars, or “below overage.”

It is something of a mixed bag as it gets a one-star “much below average” rating for health inspections, but gets four-star “much above average” ratings for staffing and quality measures.

While Scotten, who became administrator in early 2015, is listed as the administrator in the state’s Jan. 31, 2017, news release, the administrator’s name has been redacted from the negative Feb. 22 inspection survey the state has posted online at its Plan of Correction reports.

A copy of the federal Feb. 22 survey of the Montana Mental Health Nursing Care Center.(Photo: State of Montana/CMS)

“It’s a real interesting place,” Moore, 72, said prior to being let go from the facility. “I enjoy that patient population. The older I get the more a geriatric population appeals to me.”

But he is troubled by the grade decline.

“Five years ago it was rated five stars,” he said. “Now it’s not. I am deeply concerned.”

Moore, whose wife Debbie one time served as the center’s director of nursing, attributes the problems at the facility to administration and credits other employees for making it work.

“We have a dedicated staff of nurses familiar with the patient population and have done a good job of meeting patients’ needs.”

Backing leadership

Barnard said she supports the administration, Scotten and its director of nursing, Heidi Southworth.

“If I didn’t have faith in the administrator and nursing director, our responses would have been different,” she said.

Zoe Barnard(Photo: State of Montana)

Barnard said there are always employees who have trouble with administrators.

“But at the end of the day she’s the boss,” she said.

Scotten declined an interview at this time.

Vicky Byrd, executive director of the Montana Nurses Association, said registered nurses recently organized in Lewistown and prides itself on having a collaborative relationship with state-run facilities.

“The Montana Nurses Association is always concerned when any regulatory agency publicly reports deficiencies with Montana health care facilities as patient safety and quality care are nurses’ No. 1 priority,” she said in an email.

Byrd said the nurses want to be included in improving patient care conditions and the recent two-star rating.

Barnard described staff morale in Lewistown as “awful.”

“It’s really hard to go through the stuff we have been going through,” she said of the recent negative surveys. “I’ve had staff tell me it’s a slap in the face.”

“It’s really hard to have gone through the process that we are going through right now. Due to the level of care they feel proud of providing every single day. I think it’s improving you know,” Barnard said. “I look at what is going on with certification, I see the long view."

She said from the perspective of tending to difficult clients, “it can be hard to hear that the care being provided is inadequate. I know the staff at NCC is very proud of what they do,” she said.

Moore believes it is unfair to grade a facility that deals as a nursing home and a place for the mentally ill on the same level of being just a nursing home.

“Our place is so different in patient population and needs from a regular nursing home; there is no comparison, but yet we are held to the same standard as a nursing home,” he said. “It demeans the good work going on there.”

Moore said even regular nursing homes have incidents of punching and other problems from time to time.

He said Montana Mental Health and Nursing Care Center takes people who can no longer benefit from psychiatric care, “and frankly, nobody else would take them.”

Chickering said it was “not atypical for nursing homes across the country to have residents with underlying mental health conditions.“

Requirements change

Chickering said all providers who want to be reimbursed by Medicaid and Medicare must be certified and meet “our minimum standards” of care.

He said nursing homes are inspected once a year and not to exceed about 17 months from a previous survey.

Steve Chickering(Photo: CMS)

Chickering said the survey in Lewistown, which was unannounced, was a combination of a complaint being filed and that it was time for an inspection.

He said new regulations have been put in place, but that providers were given ample time to comply.

“I would just comment that the requirements have been out there for quite a while, people knew about them or should have known,” Chickering said.

He said CMS has converted from a paper to a computerized survey and the new system gives survey teams more time to do observations, interviews and “trying to meet as many people as possible.”

“We think it is a real positive thing,” Chickering said. “From our vantage point, other than a few glitches here and there, it has been received very well.”

He said most nursing home inspections do not result in immediate jeopardy. But if found, the facility is required to take immediate action, come up with an action plan.

“I wouldn’t say it’s common, but it does happen, but it isn’t infrequent either,” he said. “Most nursing home inspections do not result in immediate jeopardy.”

He said a facility found not to be in substantial compliance gets 180 days to come into compliance.

Barnard said in the initial survey there was an issue about reporting to Montana Adult Protective Services (APS), which was not previously required by the state.

Officials said a recent visit from APS to Lewistown found staff was “well trained” and forthcoming on questions and had a sincere desire to make change. The facility was very clean and free from odor.

It also noted that many nursing home facilities throughout the state would benefit greatly by modeling their operations based on the facility.

Outside firm hired

Following the Feb. 22 survey, the state hired Vivage, which, according to its website, is an operator, manager and consultant for senior living communities, to work at the center.
Vivage has been at Lewistown for three months, said Nancy Schwalm, the company’s public relations spokeswoman.

She said they have also been on the Crow Reservation for one month, adding she could not provide specifics as to what they were doing at each location.

In an April 26 news release posted on its website, the company says it is continuing in its “consulting role to operators requiring consulting services or temporary management as directed by the Centers for Medicare and Medicaid Services and State Department of Health in Region 8.”

“Vivage is actively supporting this effort in two locations in Montana and one in Utah at present,” the news release states. “Vivage consultants, led by Chief Clinical Officer, Cynthia Coenen, work with facility leadership to achieve and sustain regulatory compliance.”

Schwalm said Vivage is usually hired if a skilled nursing facility does not meet regulatory compliance, albeit one or several issues.

The company helps these facilities sustain compliance.

“As you know, nursing homes have an incredible amount of regulations,” she said, “Our goal is to work ourselves out of a job.”

She said Vivage has the “freedom” to work with clients in a way that a government surveyor can’t.

“It sometimes makes a difference to their success,” she said.

Schwalm said the company has experience with the challenges facing the Lewistown facility.

Vivage operates 29 of its own nursing homes and eight of those serve residents who primarily have mental health issues.

“We are very familiar and comfortable with that situation,” she said.

Schwalm said the facilities in Montana have been “extremely cooperative and want to do the right thing.”

“It makes our job easier,” she said.

Barnard said much of what Vivage has done is training staff on documentation.

"Oftentimes with certification it’s about how you document the incident, how it gets reported and who it gets reported to,” she said.

Barnard added she hoped the visits would be completed soon.

“They have been successful in working with us and the number of visits they have been making has dropped off,” she said.

She said staff may likely handle issues the same way they always have, but there could be changes in how it is documented and reported.

“We see certification as a process. We don’t see a licensure survey or certification survey as being kind of a checkoff,” Barnard said. “We see it as being an ongoing process that happens between us and our regulatory agencies.”

Problems outlined

In the Jan. 31, 2017, DPHHS news release regarding the U.S. News and World Reports story, Scotten says the staff receives 16 hours of Mandt training annually, which focuses on dealing with behaviors using the “least restrictive methods.”

“We are always working to Improve our core values, which is teamwork and respecting everyone, and understanding and listening to our residents,” she stated.

However, the Feb. 22 CMS inspection found at least one staff member who said she had not been trained in the Mandt behavior program. She said she had been working in the Firefly wing for a year and her employer trains her on what to look for regarding resident behavior.

Health inspections include safe food preparation, medication management and residents’ rights. Staffing includes how many minutes of nursing care patients receive daily, based on data reported to CMS. One example of the 24 medical quality measures is how the facility works with patients to prevent patient falls that can cause injury.

According to the June 23, 2017, survey, the inspector found the facility failed to monitor staff members who had access to residents during and after allegations of abuse were reported.

One resident said in an earlier interaction that a staff member had accused him of doing “something to my wife a long time ago.”

The resident said he did not know who that woman was.

One staff member said sometimes when allegations arise, the staff is sometime suspended or moved to another wing.

“These residents have mental health issues so we are not always sure if the allegation is true,” the inspector quoted the staff.

The “immediate jeopardy” finding said the facility failed to identify when abuse occurred and protect residents from potential future abuse.

On April 25, 2017, staff “physically held the resident’s hands” to keep him from moving after showing he had possession of a debit card, which was against regulations. They retrieved the card and placed it in a safe, according to the report.

Another staff member said they should have waited for the resident to calm down and then removed the card.

Center makeup

The center has five wings.

Dementia patients are put into the “F” wing, also known as “Firefly.” Higher functioning ambulatory patients who may pose some security concerns are in the A wing, also known as Apple Wood, according to state officials.

Those with high incidence behaviors are placed in the Echo Lane wing and people who need help with daily living activities and need higher staffing levels are in the Glacier Way wing, according to a 2013 state report.

In 2012, the state converted the D wing into a 25-bed facility to house inmates from Montana State Prison. They require care not available in correctional facilities for chronic medical conditions. They do not have access to other areas of the building and have direct supervision.

State officials said as of May 17 there were 10 residents in the Firefly wing, 25 in Glacier Way, 22 in Apple Wood and 23 in Echo Lane. D wing is the Lewistown infirmary which is licensed as a infirmary and not included in the MMHNCC License. The Lewistown infirmary is a partnership between DPHHS and DOC. It has different regulations.

Some of the more troublesome residents are moved to the Montana State Hospital in Warm Springs, which has 270 beds and provides psychiatric treatment for adults with serious mental illness. It’s the only public psychiatric hospital in the state.

Moore said he was often irked by that.

“Shipping people back to Warm Springs was a solution I took great issue with,” he said. “It really pissed me off, to be honest. Will it change their behavior? We have more staff here. I’d rather have them have a nice place to be demented in.”

Before and after

Scotten, who previously worked for Montana Veterans Affairs, won a federal whistleblower lawsuit against the Montana VA in 2016 over an operating room error. They were ordered to pay her damages and offer her a similar job to what she held before she resigned in December 2014.

Her attorney said at the time that Scotten was now working for DPHHS and did not want to return to the VA.

The attorney said the ruling should give hope to other employees who want to speak out and would lead to change.

Moore said he is now retired and lives in a home outside of Lewistown that hugs a creek. Administration has told staff he has retired. He said that is not the case but won’t dispute it.

He didn’t get a chance to say goodbye to the residents.

“On a day-to-day basis it’s a pretty calm place,” he said, adding that some of the people he was taking care of had been there his entire 18 years at the facility.

He talks about the rare moments of clarity with a few of the residents.

“Some of these people get enjoyment out of life,” he said. “Sometimes these people do not communicate for a long time and then they will talk to you like you and I have been talking for five minutes. I’ve quit making judgments on the quality of people’s lives.”

Barnard was asked if she was concerned the center would be closed.

“We never got to that point,” she said. “I’d be very worried if they shut the facility down because these are people that other nursing homes in the state cannot and will not serve.

“We would see 100 potentially aggressive, mentally ill, aging people in need of nursing care basically put out on the street. And that would be a grave concern to me,” Barnard said.

Chickering said there would be a followup survey 45 to 90 days after the facility came into compliance with federal regulations.

“Our desire is to have every nursing home (be in compliance) and to provide good care to everybody,” he said. “We want every place to be successful and we’re hopeful the strategies in place actions fully implemented.”

Phil Drake can be reached at 406-422-0772 or pdrake@greatfallstribune.com.